Management of pericarditis: recent advances

Pericarditis is the most frequent pericardial syndrome and a common cause of chest pain in emergency and cardiology practice. During the past two decades, management has moved from largely empirical anti-inflammatory treatment towards a mechanism-based, risk-stratified, and imaging-supported approach. Diagnosis remains clinical, based on typical chest pain, pericardial rub, electrocardiographic changes and pericardial effusion, but inflammatory biomarkers and multimodality imaging, especially cardiac magnetic resonance, increasingly support diagnostic confidence, differential diagnosis, and therapeutic decisions. For most patients with acute idiopathic or presumed viral pericarditis, aspirin or a non-steroidal anti-inflammatory drug combined with colchicine is first-line therapy, with exercise restriction and follow-up guided by symptoms and C-reactive protein. Corticosteroids should be avoided when possible or used at low-to-moderate doses only for selected indications, because they promote chronicity and recurrence in unselected cases. The major recent advance is the recognition of recurrent pericarditis as an autoinflammatory, interleukin (IL)-1-mediated disease in a substantial proportion of patients with an inflammatory phenotype. Randomized and registry data now support IL-1 inhibition (eg, anakinra or rilonacept) for corticosteroid-dependent and colchicine-resistant recurrent pericarditis, allowing rapid symptom control, withdrawal of corticosteroids, and marked reduction in recurrences. Remaining challenges include optimal treatment duration, cost and access to biologics, management of patients without overt systemic inflammation, and personalized strategies for tapering and return to activity.